Original listing text, shown exactly as published by the company.
Position Responsibilities
- Medical Director will complete assigned medication utilization reviews (PA) and/or medical necessity appeals for commercial clients; governmental (Medicare/Medicaid) programs and individual client requested coverage determinations or appeals when appropriate
- Makes clinical determinations in accordance with medical necessity and criteria
- Performs scientific literature evaluation using primary, secondary, and tertiary drug resources to support decision-making and recommendations to requesting prescribers
- Follow all internal procedures, job aids, and HIPPA guidelines to protect patient privacy and data security
- Support the Department’s responsibilities to provide peer-to-peer phone call support to physicians/prescribers who call the company with specific and general questions about our clinical programs, communications and utilization review decisions
- Communicates effectively and confidently with members to promote positive health outcomes
- Actively participates in the development of utilization management (PA) criteria and clinical policy revisions/reviews
- Ability to work in a fast-paced environment with shifting priorities
- Weekend on-call responsibilities (shared rotating call)
- Attention to detail and commitment to delivering high-quality work
Minimum Qualifications
- Must be a graduate of an accredited Medical School and Residency Program
- Active Texas medical license, required
- No history of disciplinary actions on Medical License
- Minimum 5 years history of clinical practice with direct patient care
- Specialty-Internal Medicine
- Board certified by appropriate Medical Board (DO, MD)
- Be able to satisfy rotating weekend call schedule with another Medical Director
- Possess an unrestricted active license to practice medicine in a State, Territory, Commonwealth of the United States, or the District of Columbia
- Required annual Continuing Medical Education (CME) up to date and must remain current in medical and management areas during employment
- Demonstrated experience in clinical outcomes, working knowledge of medical statistics, regulatory agencies, and analytic programs
- Ability to work with virtual teams of pharmacists
- Time management skills to meet organizational goals
- Knowledge of PBM environment, quality improvement and UM practices in a managed care environment
- Knowledge of and appreciation for requirements of regulatory and accreditation agencies
- Able to manage multiple priorities and deadlines
- Excellent verbal, written, interpersonal and presentation skills
- Strong knowledge of clinical medicine, health care delivery and the ability to acquire new scientific and medical knowledge
- Proficiency with Microsoft Office applications. (e.g., MS Word, Excel, and PowerPoint minimum)
Preferred Qualifications
- Subspecialty board certification in addition to internal medicine (i.e. Rheumatology, Gastroenterology)
- Willing to obtain additional medical license
- Licensed in multiple states. Unrestricted without disciplinary actions (AZ, NC, MN, MI, TN or others)
This range represents the low and high end of the anticipated base salary range. The actual base salary will depend on several factors such as: experience, knowledge, skills, and location of the job.
Remote, US Salary Range$79,800—$126,000 USDAll employees are responsible for adherence to the Capital Rx Code of Conduct including the reporting of non-compliance. This position description is designed to be flexible, allowing management the opportunity to assign or reassign duties and responsibilities as needed to best meet organizational goals.
Judi Health values a diverse workplace and celebrates the diversity that each employee brings to the table. We are proud to provide equal employment opportunities to all employees and applicants for employment and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, medical condition, genetic information, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
By submitting an application, you agree to the retention of your personal data for consideration for a future position at Judi Health. More details about Judi Health's privacy practices can be found at https://www.judi.health/legal/privacy-policy.
